Credit Card Remittance Form For Readmit Application Fee

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Credit Card Remittance Form for Readmit Application Fee
PLEASE REMEMBER TO INCLUDE:
Your Visa, MasterCard, or American Express card number.
(We do not accept Discover)
The Cardholder’s signature
The Zip code associated with the card you are using
* Please note that without zip
code information your payment will not go through. This is to protect you against fraudulent charges.
(PLEASE PRINT)
STUDENT NAME: ________________________________
DATE: ________________
UNC CHARLOTTE ID #: _______________________________________________________
EMAIL ADDRESS: ___________________________________________________________
CARDHOLDER’S NAME: ______________________________________________________
CARD TYPE:
Visa
MasterCard
American Express
CARD NUMBER: _____________________________________________________________
EXPIRATION DATE: ____________________
PAYMENT AMOUNT: _______________
ZIP CODE ASSOCIATED WITH CREDIT CARD: _______________________________________
CARDHOLDER’S SIGNATURE: ___________________________________________________
For Readmission: Please fax your application fee payment information along with your
readmit application to our secure fax number of 704-687-1419.
*Please note that the readmit application fee is non-refundable.
Revised on 6-7-13

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